Conservative treatment of early postoperative small bowel obstruction with obliterative peritonitis

Fluoroscopic balloon dilation for early jejunojejunostomy obstruction after gastrectomy with roux-en-Y reconstruction: a case series of three patients

BACKGROUND

Small bowel obstruction after gastrectomy with Roux-en-Y reconstruction (R-Y reconstruction) is not a rare complication. However, patients who need re-operation for this complication have a high rate of postoperative complications. We report a case series of three patients who underwent fluoroscopic balloon dilation (FBD) for early jejunojejunostomy obstruction (JJO) after gastrectomy with Roux-en-Y reconstruction (R-Y reconstruction).

CASE PRESENTATION

Three patients were referred to our hospital for surgery for gastric cancer. Robot-assisted distal gastrectomy with D2 lymph node dissection and antecolic R-Y reconstruction were performed in two patients, and robot-assisted total gastrectomy with D1+ lymph node dissection and antecolic R-Y reconstruction was performed in one patient. The jejunojejunostomy was created as a side-to-side anastomosis using a linear 45-mm stapler. The entry hole was closed with a knotless barbed suture, and serosal-muscle layer suture reinforcement with an absorbable suture was performed at the jejunojejunostomy. Subsequently, all the patients were diagnosed with JJO by computed tomography and upper gastrointestinal series. The average time to JJO from gastrectomy was 5 days (range 2-7); initial clinical symptoms were vomiting in all three cases, with simultaneous upper abdominal pain in one case. We successfully performed FBD in all three cases after unsuccessful conservative treatment using an ileus tube. The clinical symptoms improved soon after FBD, and all the patients were able to avoid re-operation. The average period to FBD from JJO was 10 days (range 4-14). The average procedure time was 46 min (range 29-68), and the average duration to oral intake from FBD was 4 days (range 2-5). The average duration of hospital stay after FBD was 12 days (range 9-15). There were no complications in any of the cases.

CONCLUSION

FBD might be a feasible procedure to avoid surgery for early small bowel obstruction after gastrectomy with R-Y reconstruction.

Parenteral Nutrition Instead of Early Reoperation in the Management of Early Postoperative Small Bowel Obstruction

BACKGROUND

In majority of patients, early postoperative small bowel obstruction (EPSBO) resolves with nasogastric decompression and bowel rest alone, while in some patients, symptoms persist without urgent indications for surgery. The purpose of this study was the evaluation of home parenteral nutrition (HPN) instead of elective surgery as an initial approach to persistent EPSBO.

METHODS

Patients developing EPSBO prescribed HPN without reoperation within 6 weeks after index intestinal surgery were identified from an institutional HPN registry and retrospectively compared with patients undergoing reoperation for EPSBO within the same time period.

RESULTS

Thirty-four patients for the HPN group and 27 patients in elective reoperative (REOP) group met the inclusion criteria. In the HPN group, mean interval between surgery and PN initiation was 11 days. HPN duration ranged from 17 to 244 days with a median of 60 days. Thirty-one patients (91%) successfully recovered bowel function and resumed enteral nutrition without reoperation, while 3 patients required reoperation > 6 weeks after index surgery due to HPN failure. In the REOP group, mean interval between index surgery and reoperation was 17 days. At reoperation, 12 patients required bowel resection, 5 having incidental enterotomies, and 3 required new stoma creation. Postoperatively, 2 patients developed enterocutaneous fistulas, 1 experienced an anastomotic leak, and another had fascial dehiscence.

CONCLUSION

HPN is a safe alternative to elective surgery in clinically stable patients with persistent EPSBO. This approach avoids hazardous reoperation during the recovery phase when adhesions are at their worst.

Diagnosis and Treatment of 26 Cases of Abdominal Cocoon

BACKGROUND AND AIMS

Abdominal cocoon (AC) is a rare abdominal disease with nonspecific clinical features, and it is difficult to be diagnosed before operation and hard to be treated in clinical practice. The aim of this study is to investigate the diagnosis and treatment of AC.

METHODS

The clinical manifestations, findings during surgery, treatments, and follow-up results of 26 cases of AC were retrospectively studied from January 2001 to January 2015.

RESULTS

All of 26 cases were diagnosed as AC definitely by laparotomy or laparoscopic surgery. Their clinical findings were various, with 7 intestines obstructed with bezoars and 4 intestines perforated by spiny material. Based on the existence of the second enterocoelia, all cases were categorized into 2 types: type I is absent of second enterocoelia (18 cases, 69.23%), while type II shows second enterocoelia (8 cases, 30.77%). Twenty cases (12 were type I and 8 were type II) underwent membrane excision and careful enterodialysis to release the small intestine entirely or partially, while the other 6 cases (all were type I) did not. In addition, all patients were treated with medical treatment and healthy diet and lifestyle. Finally, most of the patients recovered smoothly.

CONCLUSIONS

AC can be categorized into two types; surgery is recommended for type II and part of type I with severe complications, but sometimes conservative therapy might be appropriate for type I. Laparoscopic surgery plays an important role in the diagnosis and treatment of AC. Furthermore, favorite health education, healthy diet and lifestyle are of significance in patients' recovery.

Fluoroscopic Balloon Dilation for Treating Postoperative Nonanastomotic Strictures in the Proximal Small Bowel: A 15-Year Single-Institution Experience

PURPOSE

To evaluate safety and effectiveness of fluoroscopic balloon dilation (FBD) for treating postoperative nonanastomotic strictures in proximal small bowel.

MATERIALS AND METHODS

Data of 44 patients (26 men and 18 women; mean age, 53.7 y ± 13.0) treated with FBD for postoperative nonanastomotic strictures in the proximal small bowel between January 2000 and February 2016 were retrospectively reviewed. Site of stricture was located in the first portion of duodenum in 8 (18.2%) patients, second portion of duodenum in 8 (18.2%) patients, third portion of duodenum in 1 (2.3%) patient, fourth portion of duodenum in 1 (2.3%) patient, and proximal jejunum in 26 (59.1%) patients. Mean distance between the most anal-side lesion and the oral cavity was 63.9 cm ± 15.0.

RESULTS

Technical success was achieved in 39 (88.6%) patients. Mean stricture length was 3.0 cm ± 1.8. Technical failure because of inability to negotiate the guide wire through the stricture occurred in 5 (13.6%) patients. Complete resolution of obstructive symptoms and resumption of oral intake of soft or solid food within 3 days occurred in 34 patients after 1 (n = 32) or 2 (n = 2) FBD sessions, rendering a clinical success rate of 87.2%. There were no major complications directly related to FBD. Median follow-up period was 1,406 days (interquartile range, 594-2,236 d). Nine (26.5%) patients had recurrence within a median 47 days (interquartile range, 20-212 d).

CONCLUSIONS

FBD may be safe and effective for treating postoperative nonanastomotic strictures in the proximal small bowel.